The management of old urethral injury in young girls: analysis of 44 cases

Background/purpose: Traumatic urethral injury in girls is rare, and there is no consensus on its management. The authors report their 22-year experience.Methods: Forty girls presented with urethrovaginal fistula. Twenty-six girls presented with cystostomy tube in place, whereas 17 girls presented with complete urinary incontinence. Incision and dilatation of the obliterated urethra was carried out in 7 patients. Vaginal repair of urethrovaginal fistula was performed in 4 patients. Transpubic reconstruction of the urethra using a modified Young-Dees-Leadbetter procedure with simultaneous repair of the urethrovaginal fistula was performed in 35 patients (once in 27, twice in 5, and 3 times in 3 patients).Results: Follow-up in 40 girls averaged 3.5 years. Twenty-nine patients have regained normal urinary control, and 11 patients have mild stress urinary incontinence. Four patients were lost to follow-up.Conclusions: Simple dilation of the obliterated urethra can reestablish satisfactory urethral patency if the obliterated segment is short. The vaginal approach to urethrovaginal fistula may be successful in patients without concomitant urethral stricture or in those with stricture amenable to simple dilation. The transpubic approach remains the method of choice for repairing complete urethral disruption and severe urethral stricture, especially when associated with urethrovaginal fistula.     

The use of pedicled appendix graft for substitution of urethra in recurrent urethral stricture

Background: Recurrent posterior urethral strictures after failed urethroplasty may need urethral substitution. Skin or mucosal grafts, currently used for this purpose, have a high complication rate. The authors describe the use of pedicled appendix for posterior urethral substitution. Methods: Two boys with pelvic fracture urethral distraction injuries were treated for recurrent posterior urethral strictures after a failed perineal anastomotic urethroplasty. Through a perineal-transpubic approach the stricture tissue was excised, which resulted in a gap of 5 to 7 cm between the healthy ends. The vermiform appendix was mobilised on its own pedicle and transposed to the perineum; the proximal end of appendix was anastomosed to the prostatic urethra and the distal end (tip discarded) to the bulbar/penile urethra. Omentum was transposed to wrap the anastomosis and fill the dead space. Results: Normal micturition was restored in both patients. No further treatment was required after 1 dilatation in the first case. Both patients are continent. Potency status remains unchanged from the preoperative period with normal erections in 1 case. Follow-up (1 to 3 years) has been satisfactory with no complications. Conclusions: The appendix is a promising organ for posterior urethral replacement. It can be brought to the perineum on its own vascular pedicle.     

Guide wire-assisted urethral dilatation for urethral strictures in pediatric urology

Purpose: The aim of this study was to report the results of 32 cases of dilatation of urethral stricture using a guide wire and sheath dilator technique supplemented by clean intermittent catheterization if further stabilization of the urethral stricture was felt warranted.Methods: The procedure involves insertion of a straight flexi-tip lubricated guide wire through the urethral stricture under cystoscopic guidance followed by insertion of a series of sheath dilators. Dilatation was followed by insertion of a Foley catheter, which was left in situ for 1 to 3 days. Patients underwent repeat cystoscopy to evaluate the urethra for recurrent stricture and those with a recalcitrant stricture were commenced on clean intermittent catheterization (CIC) to stabilize the narrowing.Results: Thirty-two patients were included. They have been followed up for up to 2 years after their last cystoscopy (mean, 16 months). Thirteen of 32 patients had more than 4 dilatations under anesthesia. Twelve patients had undergone CIC postoperatively. Complications included a urinary tract infection in 3 boys and bladder spasms in one. No false passage or sepsis occurred with this approach.Conclusions: Guide wire-assisted urethral dilatation helps avoid risks associated with blind dilatation techniques and appears to be a safe and simple alternative for management of urethral strictures in pediatric urology.     

Immediate Management of Posterior Urethral Disruptions Due to Pelvic Fracture: Therapeutic Alternatives

Purpose

We retrospectively reviewed the results of 3 types of initial management of pelvic fracture urethral disruption in children.

Materials and Methods

From 1980 to 1994, 35 boys 2 to 15 years old (mean age 8.1) with prostatomembranous urethral disruption were treated, including 17 who also had associated injuries. Immediate treatment included suprapubic cystostomy and delayed urethroplasty in 19 patients (group 1), urethral catheter alignment without traction and concomitant suprapubic cystostomy in 10 (group 2), and primary retropubic anastomotic urethroplasty in 6 (group 3).

Results

In all patients in groups 1 and 2 severe urethral obliteration developed. Four group 3 patients (66%) had a stricture at the site of anastomotic repair. After delayed urethroplasty 16 group 1 (84%) and all 10 group 2 patients were continent. However, only 3 group 3 patients (50%) achieved continence. Retrospectively associated bladder neck injury occurred in 5 of the 6 incontinent boys. Erections were observed before and after treatment in all but 3 children. Unstable pelvic ring fractures (type IV) comprised 28% of all pelvic fractures with a high rate of associated injuries.

Conclusions

As described, urethral alignment was not beneficial for avoiding urethral obliteration. Therefore we recommend suprapubic cystostomy as the only form of initial treatment in these cases. Urinary incontinence seems more likely related to associated bladder neck rupture and the severity of pelvic fracture rather than to initial treatment or delayed urethral repair. Consequently, when associated bladder neck injury is present, we advocate immediate surgical repair.     

1-Stage delayed bulboprostatic anastomotic repair of posterior urethral rupture: 60 patients with 1-year followup

PURPOSE: The long-term results of delayed 1-stage bulboprostatic anastomotic urethroplasty for posterior urethral ruptures are evaluated. MATERIALS AND METHODS: A total of 63, 1-stage delayed repairs of complete posterior urethral ruptures in 60 men with at least 1-year followup were reviewed. Two ruptures were due to gunshot wounds and 58 were secondary to a pelvic fracture. There were 58 repairs done by the perineal approach and 5 required an abdominal perineal approach. RESULTS: Surgical complications included 2 (3%) rectal injuries, 3 (5%) repeat strictures that required reoperation and 20 (32%) repeat strictures that required dilation or visual internal urethrotomy. By 1 year after surgery all patients had a patent urethra and did not require further treatment. At 1 year 43 (72%) patients voided normally, 5 (8.3%) were areflexic and performed self-catheterization, 5 (8.3%) had urge incontinence and 5 (8.3%) had mild stress incontinence requiring no treatment. Moderate stress incontinence responded to imipramine in 1 case and collagen injection in 1. Of the patients who were potent preoperatively 31 (52%) remained potent postoperatively. Of the 29 (48%) patients who were impotent preoperatively and immediately postoperatively 9 regained potency at 1 year. However, at 1 year, the quality of erections of the 40 potent men was normal in only 22 (37%) and fair to poor in 18 (30%). CONCLUSIONS: The 1-stage delayed bulboprostatic anastomotic urethroplasty has a good long-term result with little morbidity for treatment of posterior urethral ruptures in men.     

The effectiveness of early primary realignment in children with posterior urethral injury

AIM: The aim of this retrospective study was to compare the results of delayed repair and early primary realignments in patients with posterior urethral injury. METHODS: From 1990 to 2003, 20 children were admitted to the Medical Faculty of Uluday University, Bursa, Turkey, for posterior urethral injuries. Traffic accidents were the most common cause of injury (n = 17). Twelve patients (60%) who were referred early (1-10 days) underwent early realignment over a urethral tube. A total of eight patients (40%) underwent delayed repair using transpubic route. In these patients, surgical repair of the urethra was performed 5-6 months later. RESULTS: Of the 12 patients who underwent early urethral realignment, six required at least one visual internal urethrotomy following the removal of the urethral catheter. Urethral stricture developed in two of 12 patients (16.6%) who underwent early urethral realignment. Of the eight patients who underwent delayed repair, six required at least one visual internal urethrotomy following removal of the urethral catheter. Urethral stricture developed in three of eight patients (37.5%) who underwent delayed repair. This difference was statistically significant (P < 0.05). CONCLUSION: The urethral stricture in patients who underwent early primary realignment was less developed than the stricture that developed in those who underwent delayed management. According to these results we recommend early primary realignment in children with posterior urethral injury.     

小儿尿道损伤的诊断与治疗

目的：探讨小儿尿道外伤及外伤后尿道狭窄的诊治经验。方法：在8例新鲜完全性后尿道断裂患儿中,3例行经耻骨上与会阴入路的尿道修复术,2例行尿道会师术,2例行膀胱造瘘术,1例女童行经耻骨后尿道吻合术。在18例陈旧性后尿道外伤患儿中,10例行经尿道内切开（TUR）术,4例行经耻骨、会阴联合入路修复术,4例行经会阴修复术。结果：8例新鲜后尿道断裂患儿中,术后出现尿道狭窄5例,不完全尿失禁1例。18例陈旧性尿道蛱雅患儿中,行TUR的成功率为60．0％,经会阴及经耻骨、会阴联合入路行尿道修复术的成功率为91．7％,有不完全尿失禁5例,会阴尿道造瘘尚未修复1例。结论：后尿道外伤的急症处理非常重要,如患儿情况允许,应尽量行经耻骨、会阴联合入路尿道修复术。经尿道内切开适用于绝大多数单纯性后尿道狭窄,经耻骨、会阴联合入路或经会阴修复尿道适用于复杂性后尿道狭窄或TUR失败者。     

Avoidance of leakage and strictures when creating an invisible conduit for antegrade colonic enemas

Background: Antegrade enemas have been proven to minimize problems with stool control for many incontinent patients; however, foreign bodies are unsightly, and native tissues have been shown to leak or stricture. Methods: Using a limited laparotomy incision, the appendix or a rolled cecal tube was sutured to the apex of the everted umbilical skin using a V-shaped incision. The skin then was inverted to hide the mucosa. The cecum was plicated around the base of the appendix or cecal tube and then tested by filling the cecum with saline to a pressure of 30 cm H₂O. Results: Twenty patients (aged 4.8 to 41 years) with fecal incontinence caused by imperforate anus (17 cases) and other causes underwent this procedure. Two patients had minor strictures that resolved with home dilatations, and one cecal tube necrosed, and the patient has refused reoperation. One patient had minor prolapse and underwent revision. None of the conduits leak. Two patients achieved continence and stopped cannulating their stomas. With adjustment and customization of each enema regimen, stool accidents are infrequent. Follow-up is 22 [plusmn] 14 (mean [plusmn] SD) months. Conclusion: A catheterizeable colocutaneous conduit has been developed that allows for an invisible, leak-proof, and relatively stricture-free means through which antegrade enemas can be given.     

Initial management of anterior and posterior urethral injuries

The key to the initial management of a urethral injury is prompt diagnosis, accurate staging of the injury, and properly selecting an intervention that minimizes the overall chances for the debilitating complications of incontinence, impotence, and urethral stricture. Although somewhat controversial, blunt traumatic posterior injuries generally are managed best by primary realignment (when feasible), straddle injuries of the bulbar urethra by suprapubic urinary diversion, and penetrating urethral injuries by primary repair and urinary diversion.     

Urethral injury in the multiple-injured patient

A total of 74 patients with urethral injury due to external trauma consisted of 48 posterior urethral injuries (25 complete rupture, 23 partial rupture) and 26 anterior urethral injuries (two complete rupture, 16 partial rupture, and eight contusion). The diagnosis was made by retrograde urethrography. All 48 patients with posterior urethral injury had associated injuries, including a fractured pelvis in 46, and a mortality rate of 33%. Only seven of the 26 patients with anterior urethral injury had associated injuries and a mortality rate of 14%. The management of posterior urethral injury is changing from primary realignment of the ruptured urethra to suprapubic cystostomy alone and followed later by urethral surgery for the resulting stricture. The impotence rate is significantly lower with management with suprapubic cystostomy alone. However, the type of pelvic fracture, the urethral injury itself disrupting neurovascular structures, and the surgical dissection (initial primary realignment or delayed urethroplasty) must be investigated before it can be determined whether the impotence associated with pelvic trauma is caused by the injury itself or by the surgical dissection undertaken to reconstruct the urethra.     

Balloon catheter dilatation in children with congenital and acquired esophageal anomalies

Background/Purpose: Esophageal stricture requiring dilatation often is the sequelae in children with a history of congenital or acquired esophageal anomalies. Balloon catheter dilatation (BCD) for esophageal stricture is well established in adults, yet its role in children is less well described. The authors report their initial experience using BCD in children with esophageal stricture, assessing outcome. Methods: Between January 1994, and December 1998, 20 children (age range, 17 days to 12 years) underwent BCD for esophageal strictures and were divided into 2 etiology groups (A and B). (A, n = 10) included congenital anomalies (esophageal atresia, 10), and (B, n = 10) included acquired anomalies (caustic ingestion, 7; tight fundoplication, 2; peptic stricture, 1). BCD was performed in all cases under conscious sedation with a balloon catheter (6 to 25 mm) with fluoroscopy. Outcome parameters included number of dilatations; complications, ie, perforation; and success or failure of procedure. Success was defined as increasing intervals of age-appropriate food tolerance between dilatations, and failure was defined as abandonment of dilatation in favor of surgical intervention. Follow-up for A and B ranged from 6 to 42 months. Results: Seventeen of 20 (85.0%) underwent successful BCD. In A, 10 of 10 (100%) had complete resolution of symptoms with follow-up ranging from 6 to 42 months versus 7 of 10 (70.0%) in B with follow-up of 6.5 to 36 months. In A, number of dilatations ranged from 1 to 4 over an average period of 2 months. In B, number of dilatations ranged from 3 to 40 over periods ranging from 2 to 30 months. All 3 failures occurred in children with caustic ingestion, with 1 child suffering perforation requiring urgent surgical intervention. Conclusions: Balloon catheter dilatation can be applied safely and effectively to children in whom esophageal strictures develop after repair of esophageal atresia. However, its use in children with acquired esophageal anomalies, notably caustic injury, is associated with higher complication and failure rates, necessitating greater caution and lower expectations.     

Pelvic Fracture Urethral Injuries: Evaluation of Various Methods of Management

Purpose

The results of various immediate treatments of urethral injuries complicating a fractured pelvis were evaluated.

Materials and Methods

The records of 100 male patients with pelvic fracture urethral injury were reviewed, 73 of whom were treated by suprapubic cystostomy and delayed repair, 23 by primary realignment and 4 by primary suturing. Also, the findings of 771 patients reported in the literature were reviewed.

Results

Urethral stricture was an almost inevitable consequence (97 percent of the cases) after suprapubic cystostomy. Primary realignment decreased the incidence of stricture to 53 percent but produced a 36 percent impotence rate. Primary suturing also decreased the incidence of stricture to 49 percent but produced the greatest complication rates for impotence (56 percent) and incontinence (21 percent).

Conclusions

Suprapubic cystostomy alone is indicated for incomplete urethral rupture, slight urethral distraction and critically unstable patients, and when there are inadequate facilities or inexperienced surgeons. Primary realignment is advised if there is wide separation of the urethral ends, or associated injury of the bladder neck or rectum. Primary suturing is not recommended for any condition.     

Urethral injury due to external trauma

Fifty-six patients with urethral injuries comprised 35 involving the posterior urethra and 21 involving the anterior urethra. Immediate retrograde urethrography confirmed the clinical diagnosis made when blood was found at the external urinary meatus after external trauma. Traffic accidents caused most of the posterior urethral injuries and were associated with severe injuries to multiple systems and a significant mortality rate (34 per cent). Primary realignment of the urethral injury by a urethral catheter in all cases of urethral rupture (plus a suprapubic cystostomy in most of these cases) resulted in a stricture rate of 62 per cent on follow-up. However, only half of these strictures required surgical correction. The incidence of incontinence was 10 per cent and of impotence 38 per cent.     

Experiencia en reconstrucción postraumática de uretra posterior en niños. Hospital Universitario San Vicente de Paúl. Medellín 1987-2007

ObjectiveIn order to evaluate the efficacy of different surgical techniques for the correction of traumatic lesions of the urethra, we performed a retrospective study in those patients, and evaluated different complications such as postsurgical stenosis of the urethra, incontinence and impotence (erectile dysfunction).MethodsA retrospective study was conducted, reviewing the clinical charts of 43 patients admitted to the San Vicente of Paul Hospital, with diagnosis of traumatic rupture of the posterior urethra from 1987 to 2007. We analyzed different demographic data, type of surgical correction, early and late complications.ResultsThe average age of the patients was 7.7 years, the average follow up was 30.6 months, and all the patients were male with a posterior urethral rupture.27 Patients underwent a primary urethral repair (63%), 13 patients underwent a cistostomy with later urologic reconstruction (30%), in 3 patients (7%) other surgical procedures were made.Overall complication rate was 39.5%. These complications were: Urethral stenosis, 26 patients (60.5%), urinary retention secondary to obstruction, 10 patients (23.3%), incontinence 10 patients (23.3%) and impotence 7 patients (16.3%).Patients treated with a primary urethral repair presented a significantly less development of infection, obstruction and stenosis. (p<0.05). Patients with pelvis fracture associated to urethral trauma had a significant higher risk of developing stenosis and impotence. (p<0.05).ConclusionsBoth different surgical techniques compared showed a similar complication and morbidity rates in middle follow up. Each procedure should be selected according to clinical condition of the patient, the extension of the urethral damage, the associated traumatic lesions and the surgeon`s expertise. In our searched patients, treated with a primary urethral repair we found a significantly less development of infection, obstruction and stenosis.Keywords: Trauma of urethra posterior. Children. Primary urethral repair. Cistostomy with later urologic reconstruction.     

Trauma to the anterior urethra: diagnosis and management

Injuries to anterior urethra are uncommon, mainly due to blunt trauma, and rarely associated with pelvic fractures or life threatening multiple lesions. Straddle type injury is the most frequent lesion, in which the immobile bulbar urethra is crushed or compressed on the inferior surface to the pubic symphysis. Diagnosis of urethral injury is easy, suspected due to trauma circumstances, presence of urethrorragy or initial hematuria, and eventually difficult micturition and penile scrotal for perineoscrotal hematoma. It should always be confirmed and classified by retrograde urethro-gram, realized either immediately or after a few days. Initial acute management is suprapubic cystostomy, if possible before any attempt of urethral catheterization or miction. Urethral contusions only require this urinary diversion or urethral catheter for a few days and usually heal without any sequelae. Management of partial and complete disruptions remains controversial: suprapubic diversion only and secondary endoscopic or open surgical repair of the urethral stricture that occurs in the great majority of the cases (always after complete disruption), early endoscopic realignment and prolonged urethral catheterization (4 for 8 weeks according to the lesion), in partial disruptions, more controversial in complete disruptions; delayed (after a few days) open surgical repair (urethrorraphy) that is the preferred European and French attitude for complete disruptions. Penetrating anterior urethral trauma and urethral lesions associated with penile fracture require immediate surgical exploration and repair if possible. After anterior urethral disruption, the main morbidity is urethral stricture very often requiring surgical treatment (visual urethrotomy if the structure is short, end to end spatulated urethrorraphy, flap or graft urethroplasty if longer).     

Urologic injuries associated with repair of anorectal malformations in male patients

Background/Purpose: Serious injuries to the urinary tract may occur during the repair of an anorectal malformation, especially in boys. This review of a large series of patients characterizes factors that may either lead to, or prevent, those injuries. Methods: A retrospective review of 1,003 boys with anorectal malformations was performed. Results: A total of 129 injuries in 1,003 patients were identified. Five hundred seventy-two of the 1,003 patients (group A) underwent definitive repair at the authors' institution. In this group, there were 19 urologic injuries; 1 bladder perforation, 1 divided ureter, 2 divided vas defera, 1 prostatic injury, 7 seminal vesicles were opened and closed, and in 7 cases, the urethra was opened and closed during the repair. Follow-up ranges from 15 years to 1 month and no late sequelae have been observed. The second group (B) consisted of 431 patients who underwent various operations at other institutions. In this group, 110 urologic injuries in 97 patients were noted. These included neurogenic bladder (n = 27), persistent, recurrent or acquired recto-urethral fistulae (n = 30), posterior urethral diverticulae that required reoperation (n = 23), urethral injuries leading to stenosis or aquired atresia (n = 19), pull-through of major urinary structures (n = 2), injured ureter (n = 1), opened seminal vesicle (n = 1), divided vas defera (n = 4), impotence (n = 1), and loss of ejaculation (n = 2). Several significant associations were noted. The most significant was that all 27 patients with neurogenic bladder and all 19 of those in group B with urethral injuries did not undergo a distal colostogram to define the level of the fistula before repair. Posterior urethral diverticulae were seen only in cases of recto-bulbar urethral fistulae repaired via an abdominal-perineal approach. Conclusions: Significant urologic injuries are associated with the repair of anorectal malformations. The risk of injury is increased in those patients who undergo repair without a distal colostogram.     

Female urethral injuries associated with pelvic fracture: a systematic review of the literature

To review systematically the literature on female urethral injuries associated with pelvic fracture and to determine the optimum management of this rare injury. Using Meta‐analysis of Observational Studies in Epidemiology criteria, we searched the Cochrane, Pubmed and OVID databases for all articles available before 30 June 2016 using the terms ‘female pelvic fracture urethroplasty’, ‘female urethral distraction’, ‘female pelvic fracture urethral injury’ and ‘female pelvic fracture urethra girls.’ Two authors of this paper independently reviewed the titles, abstracts, and articles in duplicate. We identified 162 individual articles from the databases. Fifty‐one articles met our criteria for full review, including 158 female patients with urethral trauma. Of these injuries, 83 (53%) were managed with immediate repair; 17/83 (20%) via primary alignment and 66/83 (80%) via anastomotic repair. The remaining 75/158 (47%) were managed with delayed repair. Rates of urethral stenosis and fistula were highest after primary alignment. Urethral integrity appears to be similar after both primary anastomosis and delayed repair; however, patients experienced significantly more incontinence and vaginal stenosis after delayed repair. Patients who underwent delayed urethral repair were more likely to undergo more extensive reconstructive surgery than those who underwent primary repair. The optimum management of female urethral distraction defects is based on very‐low‐quality literature. Based on our review of the available literature, primary anastomotic repair of a female urethral distraction defect via a vaginal approach as soon as the patient is haemodynamically stable appears to be optimal.     

男童外伤性后尿道狭窄的治疗(附210例分析)

目的　总结男童外伤性后尿道狭窄的诊治经验。　方法　陈旧性后尿道外伤患儿 2 10例。其中经尿道内切开 (TUR) 112例 ,经耻、会阴联合修复尿道 4 4例 ,经会阴修复尿道 32例 ,会阴尿道造瘘及两尿道断端间插入带蒂阴囊皮管做吻合 2 0例 ,可控性尿流改道 (Mitrofanoff术 ) 1例 ,经直肠会阴修复尿道 1例。　结果　 2 10例随访 6个月～ 14年 ,获正常排尿 187例 (89% ) ,有不全尿失禁 17例 ,会阴尿道造瘘尚未修复 5例 ,需清洁间歇导尿 1例。　结论　后尿道外伤的急症处理非常重要 ,单纯膀胱造瘘仅用于不全性尿道断裂。经尿道内切开适用于绝大多数单纯性后尿道狭窄 ,经耻、会阴联合修复尿道适用于复杂性后尿道狭窄或 (和 )闭锁段 >2cm者。     

One-stage correction of imperforate anus and rectovestibular fistula in girls: Preliminary results

Background/Purpose: This prospective study was designed to assess the safety, cost effectiveness, and advantages of performing posterior sagittal anorectoplasty without colostomy on girls with imperforate anus and rectovestibular fistula. Methods: Four girls with imperforate anus and rectovestibular fistula were entered into the study. Chest x-ray, renal ultrasound scan, and lateral fistulogram were done. Rectal pouches were washed through the fistula with NaCl and aqueous povidone-iodine solutions. Pe[ntilde]a's posterior sagittal anorectoplasties were done in the prone positions. Cephalosporin and metronidazole were given as perioperative antibiotics. Results: All patients had intermediate anomalies. There were no other major associated congenital anomalies. Washout through the fistula was easy. There were no particular problems with posterior sagittal anorectoplasty in the prone positions. Two patients had perianal skin excoriations; one had superficial infection of the posterior sagittal wound. Two patients have undergone follow-up for a year. All are having monthly dilatations. All patients pass stool without need of stool softeners or enemas. Conclusions: This preliminary study shows that it is feasible for girls with imperforate anus and rectovestibular fistula to have safe posterior sagittal anorectoplasty without colostomy. The advantages of one, instead of 3 major operations, are many, especially in developing countries. J Pediatr Surg 37:E16.     

Posterior urethral reconstruction

Summary The posterior prostatomembranous urethral stricture or distraction defect has historically been the most formidable challenge of stricture surgery. This uncommon lesion occurs most often as the sequelae of pelvic fracture injuries, or straddle trauma, and is associated with serious urethral disruption and separation – an injury that is often complicted by inappropriate initial management using substitution skin flap techniques with the development of recurrent stenosis, irreversible impotence, and occasional incontinence. Management by endoscopic techniques may be possible in patients with short strictures or in those after prostatectomy, but they rarely play a role in resolving the complex obliterated urethra with a significant defect [1]. Resolution of post-traumatic posterior urethral distraction defects and other posterior urethral pathologic conditions has dramatically improved over the past two decades despite an inaccessible subpublic location involving exposed sphincter-active and erectile neurovascular anatomy. The contemporary, perineal, one-stage bulboprostatic anastomotic operation as popularized by Turner-Warwick [20] with selective scar excision is a versatile procedure with a high patent lumen success. Patients undergoing anastomotic urethroplasty have a substained patent urethral lumen success rate approaching 100 % versus those who have undergone urethral skin flap or patch repair, where the restricture rate in 5 and 10 years increases twofold to threefold [1, 20]. A patent urethra after an anastomotic urethroplasty at 6 months is free from further recurrent stricture and gives credence to Mr. Turner-Warwick's admonition that “urethra is the best substitute for urethra”.